46 The Open Dentistry Journal, 2012, 6, 46-50

Open Access

The Use of a Disclosing Agent During Resective Periodontal Surgery for

Improved Removal of Biofilm

Marco Montevecchi, Vittorio Checchi, Maria Rosaria Gatto, Sascha Klein and Luigi Checchi*

Department of Periodontology and Implantology, School of Dentistry, Alma Mater Studiorum - University of Bologna,
Italy
Abstract: A total removal of the bacterial deposits is one of the main challenges of periodontal therapy. A surgical
approach is sometimes required in order to allow a correct access to the areas not thoroughly reached during the initial
therapy. The present study focuses on the surgical scaling effectiveness in root deposits removal; the potential support of a
disclosing agent during this procedure is also evaluated. Forty surgical periodontal patients were randomly divided
between surgeries where the operator was informed about a final examination of the residual root deposits and surgeries
where the operator was not informed. Straight after scaling procedures a supervisor recorded the O’Leary Plaque Index of
the exposed roots by mean of a disclosing agent and the percentage of teeth with residual biofilm. After the stained
deposits removal, a second chromatic examination was performed and new data were collected. Mann-Whitney U-test and
Wilcoxon test for paired samples were used for comparisons respectively between the two surgery groups and the first and
the second chromatic examination; one-sided p-value was set at 0.05. At first examination no significant differences
between the two groups were observed regarding Plaque Index (p=0.24) and percentages of teeth with residual biofilm
(p=0.07). The 100% removal of roots deposits was never achieved during the study but a significant reduction of 80% of
root deposits was observed between first and second examination (p=0.0001). Since root deposits removal during
periodontal surgery resulted always suboptimal, the use of a disclosing agent during this procedure could be a useful and
practical aid.

Keywords: Disclosing agent, biofilm, periodontal surgery, scaling and root planing.

INTRODUCTION psychological phenomenon called “Hawthorne Effect” [7]

A “biologically healthy” root surface is considered a
starting point for a natural and stable relationship between a
tooth and its surrounding periodontal tissues [1]. Therefore
the primary goal of an appropriate periodontal therapy
should be to eliminate all the bacteria and their derivate
products from the root surface [2].
A successful deposits removal depends upon correct
management and understanding of multiple factors that can
be grouped into the following three categories: instruments
used, operator skills and visibility level.
Regarding instruments available, we assisted to a strong
innovation surge over recent years. Miniaturized instruments
with new forms, surfaces and materials are now common-
place within professional practice and the improved clinical
results attained from their use have indeed lived up to expec-
tations [3-6].
Besides many are the factors that could be related to op-
erator skills. Among them some are inevitably subjective and
extremely difficult to be controlled; others instead, even if
operator dependent, are more related to the circumstances
and, as a result, potentially more controllable. A particular
*Address correspondence to this author at the Department of Periodontol-
ogy and Implantology, School of Dentistry, Alma Mater Studiorum,
University of Bologna. Via S. Vitale 59, 40125 Bologna, Italy;
Tel: +39/0512080115; Fax: +39/0514391718;
E-mail: luigi.checchi@unibo.it
belongs to the last group; this effect refers to the tendency of
some people to work harder and perform better when they
are participants in an experiment. Persons may change their
behavior due to the attention they are receiving from
researchers rather than because of any manipulation of
independent variables. This interesting variable should be
considered each time the productivity of an operator is
evaluated.
The last group of categories concerns the level of visibil-
ity of the clinician. Actually, the possibility to visualize the
area of interest and thus its accessibility for cleansing has
always been a crucial factor affecting the periodontist choice
of treatment strategy [8]. The lack of visibility is often con-
sidered as a sufficient reason to decide for the surgical inter-
vention. Though important technological innovations have
undoubtedly enhanced the diagnostic-therapeutic potential of
the clinician, a direct visual methodology is still deemed to
be the best capable system of guaranteeing the highest re-
moval percentage of bacterial deposits [9,10]. Apart from the
obvious anatomical impediments associated with the visuali-
zation of subgingival areas, difficulties associated with the
complete removal of bacterial deposits within the supragin-
gival areas have also been previously demonstrated [11]. An
extremely functional approach to this problem is the use of
staining substances that adhere to the bacterial deposits on
the tooth surfaces. The consequential improved visibility of
the biofilm becomes a crucial factor for its simple and more
effective removal.

1874-2106/12 2012 Bentham Open

Resective Periodontal Surgery and Disclosing Agent.
Fig. (1). Palatal view of the target area just before surgery.
Fig. (2). Palatal view after flap rising: submarginal surfaces are
now exposed and calculus is detectable.
Fig. (3). Palatal view during disclosing agent application.
Aim of this study was to clinically evaluate the scaling
effectiveness during osseous resective surgery and the poten-
tial aid of a disclosing agent during this procedure.
The influence on the scaling results induced by the opera-
tor awareness of a final supervision was also analyzed.
MATERIALS AND METHODS
From the patients attending the Department of Periodon-
tology and Implantology of the “Alma Mater Studiorum”
University of Bologna, a sample of 40 consecutive subjects
fitting the following inclusion criteria was selected: presence
of chronic periodontal disease in a moderate degree, neces-
sity for the patient to undergo osseous resective periodontal
surgery and absence of a declared allergy to any of the dis-
closing agent (Red-Cote
, Butler) components. A periodon-
tist not involved in the trial enrolled the participants.
In accordance with the principles of the Helsinki declara-
tion of 1975, as revised in 2000, each patient enrolled in this
study received a verbal and written explanation of the project
and subsequently signed an informed consent form for par-
ticipation.
The Open Dentistry Journal, 2012, Volume 6 47
Fig. (4). Palatal view after disclosing agent washing: stained
biofilm and calculus are now clearly detectable.
The surgical treatments (apically positioned flap with os-
seous resective surgery) were performed upon 20 patients
where the operator was informed about the planned post-
treatment chromatic examination by a supervisor and upon
20 patients where the operator was not previously informed
about the examination. The patient allocation was random-
ized: numbers among 1 to 40 were inserted in a box and than
extracted until every surgery was assigned. A pair number
identified a patient treated by an informed operator and an
odd number identified a patient treated by a not informed
operator. The supervisor, an experienced periodontist, gener-
ated the allocation sequence and assigned the participants to
their groups. Participants and operators were blinded to the
group assignment.
In order to reduce the effects that operator fatigue and
skill might have upon the study results, two operators with
extensive periodontal experience performed all surgical in-
terventions at the workday beginning. Following the neces-
sary surgical exposure of the subgingival portions of the
teeth, the periodontist proceeded, without any time limits
imposed, with the scaling and root planing procedures using
both ultrasonic and manual instruments. In cases in which
the operator was informed about the planned controls, it was
imposed that he communicate the moment in which the
chromatic examination was to be carried out. In cases where
the operator was not previously informed, the examination
phase was performed just before suturing the flaps.
The chromatic examination, always carried out by the
supervisor, was performed as follows: the stain (1.5% w/w,
Food Red No. 104 in Japan, D&C Red No. 28 in the USA)
was applied in a passive manner using sterile swabs onto the
exposed roots, left in situ for 10 seconds and then washed
with sterile saline solution for an equal time.
The plaque index was assessed according to the O’Leary
method [12] and the teeth percentage with residual biofilm
was registered for each patient (the number of treated teeth
with at least one stained area divided by the total number of
treated teeth multiplied by one hundred).
After the removal of the stained deposits, a second chro-
matic examination was performed in order to verify if the
use of the disclosing agent could be effective in improving
the scaling results.
The lasting stains were finally cleaned away and the flap
was sutured. Figs. (1 to 5) illustrate in sequence the most
crucial steps of the technique.
48 The Open Dentistry Journal, 2012, Volume 6
Fig. (5). Palatal view after root deposits removal.
Table 1. Mean Plaque Index (PI) at First and at Second
Chromatic Examinations (p-Value: 0.0001)
Chromatic Mean PI (%) ± Standard Error Min - Max
Examination
First 48.58±3.88 20-96
Second 9.71±0.78 4-19
STATISTICAL ANALYSIS
The sample dimension was defined as follows: a level
of significance of 0.05 for a one-sided test and a power of
80% were considered, the 50% was judged as the absolute PI
acceptable reduction between the two patient populations
according to the clinical expectations. An intention-to-treat
analysis was performed blind. The Kolmogorov-Smirnov Z
test with the Lilliefors correction for significance was used
to evaluate the fit of plaque index and percentage of teeth
with residual biofilm to the Gaussian model. Consequently
to the ascertainment of the not Gaussian distribution of the
two parameters, the Mann-Whitney U-test was used to com-
pare plaque index and percentage of teeth with residual
biofilm between the two patient groups and the Wilcoxon
test for paired samples was used to compare plaque index
between the first and the second chromatic examination.
One-sided p-value at 0.05 was considered on the basis of the
research hypothesis that was a positive influence on the sur-
gical scaling result by the consciousness of a final supervi-
sion [13]. Statistical assessment of the differences between
frequencies of cleaned surfaces (lingual, vestibular, medial,
distal) was performed using the
2 test; the level of signifi-
cance adjusted for multiple comparisons by using the Bon-
ferroni method was 0.008.
RESULTS
The 40 patients forming the study sample, recruited from
July to December 2008, were 56% females and 44% males
with a mean age 51±7 years, ranging from 36 to 66. All the
participants completed the study protocol.
Table 2. Mean Plaque Index (PI) and Percentage of Teeth with Residual Plaque Related to the Operator’s Awareness about the Post-
Treatment Chromatic Examination
Operator Surgery Mean PI (%) ± Standard Error
Awareness Numbers
Yes 20 41.90±4.61
No 20 55.26±5.99
Montevecchi et al.
No complications occurred in any patients, neither during
nor after surgery.
A significant reduction (80%, p=0.0001) of the PI score
between the first and the second chromatic examination was
observed [Table 1].
The first chromatic examination revealed that a 100%
removal of the bacterial deposits was never achieved. Distri-
bution and number (%) of dental areas with identified depos-
its were as follow: 130 lingual areas (31%); 124 distal areas
(29.5%), 92 medial areas (21.9%), 74 vestibular areas
(17.6%). At this examination, the lingual and distal areas
were significantly more stained than the vestibular ones
(p=0.001) as the lingual areas were compared to the medial
ones (p=0.003).
Informing or not the operator regarding the post-
treatment examinations did not result as being significant
upon the distribution of the areas that remained unclean.
The plaque index did not differ in a statistically signifi-
cant manner between the interventions in which the perio-
dontist was informed about the final examination and those
in which the operator was not informed [Table 2].
In all cases, at least 2 teeth showed residues of biofilm at
the moment of suturing. Between the two groups of surger-
ies, the percentage of teeth with residual biofilm did not dif-
fer in a statistically significant manner but tended to because
of p=0.07 [Table 2].
DISCUSSION
In the present study, the complete removal of biofilm
residues on root surfaces during osseous resective periodon-
tal surgery with apically positioned flap was never achieved.
Moreover, informing the operator about a final supervision
of the cleansing procedures performed during the surgery did
not significantly influence the quality of the results. The last
finding suggests that the precision in the cleansing process
does not probably relate to the Hawthorne Effect. The ab-
sence of an evident role of this psychological phenomenon
could be explained in two ways: one reason could be a neg-
ligible role of it in this specific procedure and the second
reason could be the eventual presence of a major limiting
factor.
Interestingly, the use of a disclosing agent during perio-
dontal resective surgery seems to be instead effective in im-
proving the scaling and root planing results.
This finding, associated to the observation that at the first
chromatic examination the distal and lingual areas remained
more frequently unclean than the vestibular areas, suggests
that accessibility and visibility are important limiting factors
in determining the quality of the cleansing outcome.
Mean (%) of Teeth with Plaque Residues ± Standard Error
84.2±8.0
92.4±6.0
Resective Periodontal Surgery and Disclosing Agent.
Fig. (6). Third molar, devoid of periodontal problems, extracted
and stained according to the protocol of this study. Note the pig-
mented periodontal ligament and the area free of stain after a cu-
rette stroke.
Among the clinical variables, the absence of a marked
chromatic contrast between the bacterial deposits and the
dental tissues is probably one of the major limitations.
What are the effective consequences of such a limit in the
total removal of the root deposits is not known and is beyond
the scope of this study. A certain tissue tolerance is undoubt-
edly present; indeed, it has been shown that the periodontal
tissues are also able to respond favorably to surfaces that
remain partially contaminated [14]. Unfortunately the
amount of residual deposits, as threshold on tissue tolerance,
is still far from being defined. Furthermore, it must be firmly
upholded that the variability in tissue response is inevitably
subject to many factors, both inherent and external to the
individual, that in turn makes the characterization of such a
threshold truly complex [15]. To recapitulate, all causal fac-
tors should be systematically removed during the surgical
phases of treatment and all procedures that might contribute
to successfully attain the desired clinical results should be
considered. From the results of the present study it derives
the suggestion that the plaque disclosing agent, as for the
supragingival region, should also constitute a useful, practi-
cal and economical aid for the periodontist during surgical
scaling [Table 1]. Numerous in vivo and in vitro studies have
been carried out on such plaque disclosing agents but no
study has yet investigated their use during periodontal sur-
gery [16-21].
The disclosing agent used in the present study contains
Phloxine B as the staining substance, a widely used color
additive for food, drugs, and cosmetics. Few is known about
the potential toxicity of this colorant but a certain terato-
genicity has been observed on mice after a 10 days of con-
tinuative food somministration [22], however no adverse
effects have ever been reported during oral conventional use.
Hence, the application of it during a surgical exposure in a
controlled and limited quantity with commercial concentra-
tion (1.5% w/w) should be considered a safe procedure.
Preparatory to the present study, it was necessary to
evaluate, on freshly extracted teeth, the performance of the
plaque disclosing agent on periodontal ligament. As shown
in Fig. (6), erythrosine, applied following the described pro-
tocol, binds ubiquitously to the root surfaces presenting an
intact periodontal ligament. This observation brings about
the proposal that such protocols should only be considered
for resective surgery. The pigmentation of such tissue por-
tions could bring to a clinical discerning error regarding the
The Open Dentistry Journal, 2012, Volume 6 49
residual deposits and as a result to an unintentional but “ex-
tremely harmful” removal of tissues thought to be important
for reattaching and/or regenerative processes [23].
CONCLUSIONS
In conclusion this study shows that a total removal of
root deposits during an osseous resective surgery is never
obtained with conventional instrumentation. Clinical limita-
tions and visual deficiency could be the primary responsible
of the present results. In order to overcome these obstacles,
the use of a plaque disclosing agent during resective surger-
ies seems to be effective.
Though this observation, the post-operative clinical pa-
rameters remain to be assessed in order to evaluate the at-
tainable advantages that affect both recovery phases and
long-term periodontal health. Such observations would con-
stitute an interesting starting point for future experimental
studies on this subject.
ACKNOWLEDGEMENT
No external funding, apart from the support of Authors
institution, was available for this study.
CONFLICT OF INTEREST
There was no conflict of interest.
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Received: November 09, 2011 Revised: December 30, 2011 Accepted: December 31, 2011

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